Debate That Divides

How Texas Could Set National Template for Limiting Abortion Access

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Efforts to defund Planned Parenthood and calls for tighter abortion laws at the Republican presidential debate have moved abortion rights back into the national spotlight. But the real fight is at the state level. The next big Supreme Court case involving abortion is expected to come from Texas [Update: The Supreme Court is hearing the case], where a 2013 law led to the closing of many clinics and inspired abortion opponents around the country to propose similar restrictions.

The law’s effects in Texas show the degree to which regulations ostensibly about clinic quality and women’s safety can reduce access to abortion and raise costs for women who choose the procedure.

Texas is now home to 17 abortion clinics, down from 41 in 2012, just before the law was passed. The 17 are almost all in major cities in the central and eastern part of the state, which are more able to fulfill the new requirements.

The average Texas county is now 111 miles from the nearest clinic, up from 72 miles in 2012. This is substantially higher than the national average outside Texas, 59 miles, and more than triple the average in deep red South Carolina, 36 miles.

The restrictions, part of House Bill 2, require clinics to meet ambulatory surgical center standards, and physicians to have admitting privileges at a local hospital. Proponents of the bill say they were seeking to safeguard women’s health; abortion rights supporters say the regulations are medically unnecessary and present an “undue burden” on women’s rights that they will challenge in court.

The impact of House Bill 2 is felt the most in western Texas, which is more rural. Lubbock and Midland each had clinics in 2012. Today, women there have to travel more than 250 miles to get to the nearest clinic: to Fort Worth for women from Lubbock, and to New Mexico for women from Midland.

And these counties aren’t alone. A fifth of Texas counties, primarily in the western half of the state, are more than 100 miles farther from a clinic today than they were in 2012.

Another way to understand abortion access in Texas is to compare it with the state of Washington, which is similar to Texas in population density but has not imposed major abortion restrictions in the decades since the Supreme Court’s Roe v. Wade decision. If abortion clinics were as common in Texas as they are in Washington, 79 Texas counties would be home to a clinic, up from seven today and 16 in 2012. As seen in the map, this would put women throughout the state much closer to a clinic.

Distance to an Abortion Clinic in Texas

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Joe Pojman, the executive director of the Texas Alliance for Life, which helped organize grass-roots support for the House bill, noted that having to travel for medical care is not unique to abortion. “If you live in the Rio Grande Valley and you need specialized oncology, for example, you may be traveling to Houston,” a trip of about 350 miles, he said in an interview.

Dan Grossman, the vice president for research at Ibis Reproductive Health, countered in an interview that abortion “is the only procedure that’s being singled out in terms of all these requirements.” The sparseness of other medical services is not the consequence of legislators trying to shut down their facilities, a fundamental difference, he said.

Arguments before the Supreme Court for Whole Woman’s Health v. Cole will be expected around February, with a decision by June.

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If the regulations are found unconstitutional, shuttered clinics will be able to reopen. But if they are ruled constitutional, seven of Texas’s 17 remaining clinics will most likely be forced to close. These seven do not meet the ambulatory surgical center requirement, one of the provisions of House Bill 2, which involves having a larger nursing staff and more rigid temperature control, among other things. The Supreme Court issued a stay on that requirement while it waited for an appeal to be filed.

These seven closings would not greatly alter the distance women have to travel to a clinic; all seven clinics are within 20 miles of a clinic that could remain open, and most are within 10 miles. But they would increase the price of abortions for many women, because the seven tend to offer substantially less expensive procedures than the clinics that would remain open. These seven include the three cheapest clinics in the state, and all but one of the seven offer cheaper procedures than the average ambulatory surgical center.

For a woman in the average Texas county, the typical cost of an in-state abortion would rise 15 percent, to $701. That figure is based on the cost of the procedure at eight weeks’ gestation (the national average for women obtaining abortions) and includes a state-mandated ultrasound and counseling, as well as travel costs. The figure leaves out secondary costs, such as lost wages and care for a mother’s children, which can be significant but are harder to quantify. In the map, you can see how these cost increases play out throughout the state.

Cost of Obtaining an Abortion in Texas

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Some of the largest cost increases would occur in Fort Worth, where the least expensive clinic that would remain open is 30 percent more expensive than the cheapest one open today, and El Paso, home to the sole remaining abortion clinic in western Texas.

These higher prices aren’t a coincidence. Converting one of these less expensive clinics to an ambulatory surgical center would probably cost over $1 million and increase the clinic’s annual operating costs by $600,000 to $1 million, according to the testimony of Anne Layne-Farrar, an economist with expertise in cost-benefit analysis, to the district court as part of the case.

Stephanie Toti, the lead litigator for the Center for Reproductive Rights, said that without such upgrades — which seem unlikely for most clinics — the remaining clinics would become overcrowded. Longer wait times would push abortions later into a pregnancy, when they’re more expensive, and possibly beyond the legal limit, 20 weeks’ gestation in Texas.

This fight over these stringent licensing requirements has become a new front in the abortion battle. Mississippi, Louisiana and 26 other states have also passed ambulatory surgical center or admitting privileges regulations, and more are expected to raise the issues in their next legislative sessions. After several years in which abortion seemed to recede as a political issue, it now seems to be coming back, at both the state and national level, including, in all likelihood, in the 2016 presidential campaign. The debate could be in full swing when the Supreme Court is expected to issue its ruling.

The list of clinics was curated from Planned Parenthood, the National Abortion Federation, Fund Texas Choice, Ibis Reproductive Health and clinic websites in July 2015, with the Guttmacher Institute’s aggregated clinic census data used as guidance. Procedure costs were self-reported by the clinics, and travel costs were estimated using data from GasBuddy and STR.

A version of this article appears in print on August 20, 2015, on Page A3 of the New York edition with the headline: Texas Could Be a Template for Reducing Abortion Access. Order Reprints|Today's Paper|Subscribe